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Pseudostandardized Patients in Undergraduate Nursing Health Assessment

Shona M. Rue, MSN, CPNP, CNE; Jessica Doolen, PhD, APRN-C, CNE

Abstract

Assessment and communication skills are essential components of nursing practice. With the current focus on student-centered learning in nursing education, nurse educators are challenged to incorporate interactive and realistic clinical scenarios into their teaching (Lehr & Kaplan, 2013). New teaching strategies are necessary to assist students in the transition from assessment and communication skills learned in the laboratory setting to the application in the clinical setting (Benner, Sutphen, Leonard, & Day, 2010). Standardized patients (SPs) are paid professional actors specifically trained to simulate real patients and provide students with realistic experiential learning (Barrows, 1993). SPs are trained to simulate a patient with a specific condition or disease process. In addition, SPs undergo training to assess competencies in history taking, communication, and physical examination skills (Barrows & Abrahamson, 1964; Owens & Gilva-McConvey, 2015). These types of competencies are subject to both formative and summative evaluation from the SP and can complement faculty assessments. In a traditional SP program, the SP provides verbal feedback to the learner immediately following the SP encounter. The incorporation of an SP program is a complex multistep process. This process takes time to interview, hire, train, pilot, and then portray an actual patient with a specific condition (Owens & Gilva-McConvey, 2015). Consequently, SP programs are costly and often reserved for advanced practice nursing education programs and medical and residency programs (Anderson, Holmes, LeFlore, Nelson, & Jenkins, 2010).

In an effort to achieve the positive learning outcomes that a formal SP program can provide, without the cost, a pseudostandardized patient (pseudo-SP) program was developed for an undergraduate nursing health assessment course. The goals of the pseudo-SP program were twofold: (a) to provide a safe and realistic environment for undergraduate nursing students to complete patient health histories and physical examinations, and (b) to offer prenursing students an opportunity to participate in an undergraduate nursing comprehensive health assessment competency practicum. On the basis of course objectives and a comprehensive health assessment grading rubric, nursing students were expected to demonstrate efficient assessment skills and effective communication skills, individualize health assessments, and accurately articulate assessment data. Prenursing students are usually enthusiastic about nursing and interested in gaining insight, or a behind-the-scenes look, into nursing programs. Undergraduate nursing health assessment students require practice with their communication techniques and assessment skills to gain confidence and proficiency. Combining these two entities was the basis for the pseudo-SP program. The term pseudo was used to reflect that prenursing student volunteers closely resembled SPs but were not trained or paid SPs. Nursing students usually practice assessment and communication skills with each other in a nursing laboratory and rotate the role of nurse and patient; however, it is not a realistic patient situation because both roles are portrayed by nursing students. Using pseudo-SPs provides realism during the health assessment practicum examination.

The first step was to obtain volunteers from a prenursing course to act as pseudo-SPs. The pseudo-SPs completed a consent form and then were provided with a brief script that included their assigned fictitious name, allergies, reason for seeking care, basic family history, and a short medical history on the day of the assessment practicum testing. Nursing students were given 40 minutes to complete a comprehensive health assessment on an assigned pseudo-SP in a designated standardized patient clinic room at a clinical simulation center. At the end of the comprehensive health assessment, the pseudo-SP evaluated the nursing student with a short performance rubric that had a section for written comments. The nursing students were also graded by faculty on their communication skills, ability to take a basic health history, and ability to complete a comprehensive physical examination…

Assessment and communication skills are essential components of nursing practice. With the current focus on student-centered learning in nursing education, nurse educators are challenged to incorporate interactive and realistic clinical scenarios into their teaching (Lehr & Kaplan, 2013). New teaching strategies are necessary to assist students in the transition from assessment and communication skills learned in the laboratory setting to the application in the clinical setting (Benner, Sutphen, Leonard, & Day, 2010). Standardized patients (SPs) are paid professional actors specifically trained to simulate real patients and provide students with realistic experiential learning (Barrows, 1993). SPs are trained to simulate a patient with a specific condition or disease process. In addition, SPs undergo training to assess competencies in history taking, communication, and physical examination skills (Barrows & Abrahamson, 1964; Owens & Gilva-McConvey, 2015). These types of competencies are subject to both formative and summative evaluation from the SP and can complement faculty assessments. In a traditional SP program, the SP provides verbal feedback to the learner immediately following the SP encounter. The incorporation of an SP program is a complex multistep process. This process takes time to interview, hire, train, pilot, and then portray an actual patient with a specific condition (Owens & Gilva-McConvey, 2015). Consequently, SP programs are costly and often reserved for advanced practice nursing education programs and medical and residency programs (Anderson, Holmes, LeFlore, Nelson, & Jenkins, 2010).

Program Development

In an effort to achieve the positive learning outcomes that a formal SP program can provide, without the cost, a pseudostandardized patient (pseudo-SP) program was developed for an undergraduate nursing health assessment course. The goals of the pseudo-SP program were twofold: (a) to provide a safe and realistic environment for undergraduate nursing students to complete patient health histories and physical examinations, and (b) to offer prenursing students an opportunity to participate in an undergraduate nursing comprehensive health assessment competency practicum. On the basis of course objectives and a comprehensive health assessment grading rubric, nursing students were expected to demonstrate efficient assessment skills and effective communication skills, individualize health assessments, and accurately articulate assessment data. Prenursing students are usually enthusiastic about nursing and interested in gaining insight, or a behind-the-scenes look, into nursing programs. Undergraduate nursing health assessment students require practice with their communication techniques and assessment skills to gain confidence and proficiency. Combining these two entities was the basis for the pseudo-SP program. The term pseudo was used to reflect that prenursing student volunteers closely resembled SPs but were not trained or paid SPs. Nursing students usually practice assessment and communication skills with each other in a nursing laboratory and rotate the role of nurse and patient; however, it is not a realistic patient situation because both roles are portrayed by nursing students. Using pseudo-SPs provides realism during the health assessment practicum examination.

Process

The first step was to obtain volunteers from a prenursing course to act as pseudo-SPs. The pseudo-SPs completed a consent form and then were provided with a brief script that included their assigned fictitious name, allergies, reason for seeking care, basic family history, and a short medical history on the day of the assessment practicum testing. Nursing students were given 40 minutes to complete a comprehensive health assessment on an assigned pseudo-SP in a designated standardized patient clinic room at a clinical simulation center. At the end of the comprehensive health assessment, the pseudo-SP evaluated the nursing student with a short performance rubric that had a section for written comments. The nursing students were also graded by faculty on their communication skills, ability to take a basic health history, and ability to complete a comprehensive physical examination using the four assessment techniques of inspection, palpation, percussion, and auscultation. The pseudo-SPs were usually excited for the experience, whereas the nursing students were initially anxious; however, after the practicum examination was complete, both parties were amazed with their performance.

Program Evaluation

The pseudo-SP program was evaluated by both nursing students and pseudo-SP volunteers; in addition, faculty evaluated and graded the nursing students’ performance. A majority of nursing students (86%; 73 of 85) reported performing a comprehensive health assessment on a pseudo-SP increased their confidence with their assessment skills, whereas 92% (78 of 85) of the nursing students reported that their nursing assessment skills were challenged using a pseudo-SP. Nursing students acknowledged that although the realistic practicum challenged their assessment and communication skills, the challenge validated their knowledge base and confirmed that they were able to perform health assessments in a clinically simulated environment. Finally, 88% (75 of 85) of the nursing students reported increased competence in performing health assessments. For faculty, it was rewarding to witness the students’ success. Furthermore, nursing students provided written comments about advantages and disadvantages with using pseudo-SPs to perform a health assessment practicum test. Some of the comments and responses were:

  • Patient seemed real…the set up was realistic.
  • Helps you prepare for the real clinical setting.
  • Allows the student to use skills without knowing in advance anything about the patient and discourages preparation by memorizing a script.
  • Challenges student’s knowledge of assessment.
  • You learn how to describe your assessment in laymen’s terms to the patient.

The pseudo-SPs also completed a written questionnaire. All but two of the 63 pseudo-SP participants (97%) reported an increase in their interest in nursing as a profession, and 94% (59 of 63) reported an increased interest in the school of nursing. Pseudo-SPs’ comments included:

  • Gave me insight as to how in depth the range of knowledge [is that] I will be learning.
  • Gained deeper insight of the tasks entailed in the nursing profession.
  • It gave me a better idea about the beginning stages of the program and how a nurse should interact with patients.
  • I got a sneak peek into what I would be doing in the nursing program.

Faculty noted that communication skills during the health assessment practicum examination with a pseudo-SP were significantly different than those seen when students practiced on their classmates. Performing assessments on classmates, rather than on strangers or pseudo-SPs, is predictable and requires little instructional guidance. Classmates are familiar with the assessment content and often anticipate the examination, whereas pseudo-SPs require directions, demonstrations, and explanations of the assessment procedures. Faculty graded nursing students on their ability to give instructions, their ability to communicate effectively and professionally, and their mannerism and organization while completing the comprehensive health assessment.

Conclusion

A pseudo-SP program is a win–win combination. Nursing students perform assessments in a pseudosimulated environment, and prenursing students gain greater exposure into the nursing profession. Not only are nursing students gaining valuable experience but increasing interest in the nursing profession is a welcome bonus. A pseudo-SP program is an innovation that adds realism at a low cost and is worth considering in an undergraduate nursing program.

References

  • Anderson, M., Holmes, T.L., LeFlore, J.L., Nelson, K.A. & Jenkins, T. (2010). Standardized patients in educating student nurses: One school’s experience. Clinical Simulation in Nursing, 6, e61–e66. doi:10.1016/j.ecns.2009.08.001 [CrossRef]
  • Barrows, H. & Abrahamson, S. (1964). The programmed patient: A technique for appraising student performance in clinical neurology. Journal of Medical Education, 39, 802–805.
  • Barrows, H.S. (1993). An overview of the uses of standardized patients for teaching and evaluating clinical skills. Academic Medicine, 68, 443–451. doi:10.1097/00001888-199306000-00002 [CrossRef]
  • Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
  • Lehr, S.T. & Kaplan, B. (2013). A mental health simulation experience for baccalaureate student nurses. Clinical Simulation in Nursing, 9, e425–e431. doi:10.1016/j.ecns.2012.12.003 [CrossRef]
  • Owens, T.L. & Gilva-McConvey, G. (2015). Standardized patients. In Palaganas, J.C., Max-worthy, J.C., Epps, C.A. & Mancini, M.E. (Eds.), Defining excellence in simulation programs (pp. 199–212). New York, NY: Wolters Kluwer.
Authors

Shona M. Rue, MSN, CPNP, CNE
shona.rue@unlv.edu

Jessica Doolen, PhD, APRN-C, CNE
University of Nevada Las Vegas

The authors have disclosed no potential conflicts of interest, financial or otherwise.

10.3928/01484834-20151016-11

Assessment and communication skills are essential components of nursing practice. With the current focus on student-centered learning in nursing education, nurse educators are challenged to incorporate interactive and realistic clinical scenarios into their teaching (Lehr & Kaplan, 2013). New teaching strategies are necessary to assist students in the transition from assessment and communication skills learned in the laboratory setting to the application in the clinical setting (Benner, Sutphen, Leonard, & Day, 2010). Standardized patients (SPs) are paid professional actors specifically trained to simulate real patients and provide students with realistic experiential learning (Barrows, 1993). SPs are trained to simulate a patient with a specific condition or disease process. In addition, SPs undergo training to assess competencies in history taking, communication, and physical examination skills (Barrows & Abrahamson, 1964; Owens & Gilva-McConvey, 2015). These types of competencies are subject to both formative and summative evaluation from the SP and can complement faculty assessments. In a traditional SP program, the SP provides verbal feedback to the learner immediately following the SP encounter. The incorporation of an SP program is a complex multistep process. This process takes time to interview, hire, train, pilot, and then portray an actual patient with a specific condition (Owens & Gilva-McConvey, 2015). Consequently, SP programs are costly and often reserved for advanced practice nursing education programs and medical and residency programs (Anderson, Holmes, LeFlore, Nelson, & Jenkins, 2010).

In an effort to achieve the positive learning outcomes that a formal SP program can provide, without the cost, a pseudostandardized patient (pseudo-SP) program was developed for an undergraduate nursing health assessment course. The goals of the pseudo-SP program were twofold: (a) to provide a safe and realistic environment for undergraduate nursing students to complete patient health histories and physical examinations, and (b) to offer prenursing students an opportunity to participate in an undergraduate nursing comprehensive health assessment competency practicum. On the basis of course objectives and a comprehensive health assessment grading rubric, nursing students were expected to demonstrate efficient assessment skills and effective communication skills, individualize health assessments, and accurately articulate assessment data. Prenursing students are usually enthusiastic about nursing and interested in gaining insight, or a behind-the-scenes look, into nursing programs. Undergraduate nursing health assessment students require practice with their communication techniques and assessment skills to gain confidence and proficiency. Combining these two entities was the basis for the pseudo-SP program. The term pseudo was used to reflect that prenursing student volunteers closely resembled SPs but were not trained or paid SPs. Nursing students usually practice assessment and communication skills with each other in a nursing laboratory and rotate the role of nurse and patient; however, it is not a realistic patient situation because both roles are portrayed by nursing students. Using pseudo-SPs provides realism during the health assessment practicum examination.

The first step was to obtain volunteers from a prenursing course to act as pseudo-SPs. The pseudo-SPs completed a consent form and then were provided with a brief script that included their assigned fictitious name, allergies, reason for seeking care, basic family history, and a short medical history on the day of the assessment practicum testing. Nursing students were given 40 minutes to complete a comprehensive health assessment on an assigned pseudo-SP in a designated standardized patient clinic room at a clinical simulation center. At the end of the comprehensive health assessment, the pseudo-SP evaluated the nursing student with a short performance rubric that had a section for written comments. The nursing students were also graded by faculty on their communication skills, ability to take a basic health history, and ability to complete a comprehensive physical examination…

Assessment and communication skills are essential components of nursing practice. With the current focus on student-centered learning in nursing education, nurse educators are challenged to incorporate interactive and realistic clinical scenarios into their teaching (Lehr & Kaplan, 2013). New teaching strategies are necessary to assist students in the transition from assessment and communication skills learned in the laboratory setting to the application in the clinical setting (Benner, Sutphen, Leonard, & Day, 2010). Standardized patients (SPs) are paid professional actors specifically trained to simulate real patients and provide students with realistic experiential learning (Barrows, 1993). SPs are trained to simulate a patient with a specific condition or disease process. In addition, SPs undergo training to assess competencies in history taking, communication, and physical examination skills (Barrows & Abrahamson, 1964; Owens & Gilva-McConvey, 2015). These types of competencies are subject to both formative and summative evaluation from the SP and can complement faculty assessments. In a traditional SP program, the SP provides verbal feedback to the learner immediately following the SP encounter. The incorporation of an SP program is a complex multistep process. This process takes time to interview, hire, train, pilot, and then portray an actual patient with a specific condition (Owens & Gilva-McConvey, 2015). Consequently, SP programs are costly and often reserved for advanced practice nursing education programs and medical and residency programs (Anderson, Holmes, LeFlore, Nelson, & Jenkins, 2010).

Program Development

In an effort to achieve the positive learning outcomes that a formal SP program can provide, without the cost, a pseudostandardized patient (pseudo-SP) program was developed for an undergraduate nursing health assessment course. The goals of the pseudo-SP program were twofold: (a) to provide a safe and realistic environment for undergraduate nursing students to complete patient health histories and physical examinations, and (b) to offer prenursing students an opportunity to participate in an undergraduate nursing comprehensive health assessment competency practicum. On the basis of course objectives and a comprehensive health assessment grading rubric, nursing students were expected to demonstrate efficient assessment skills and effective communication skills, individualize health assessments, and accurately articulate assessment data. Prenursing students are usually enthusiastic about nursing and interested in gaining insight, or a behind-the-scenes look, into nursing programs. Undergraduate nursing health assessment students require practice with their communication techniques and assessment skills to gain confidence and proficiency. Combining these two entities was the basis for the pseudo-SP program. The term pseudo was used to reflect that prenursing student volunteers closely resembled SPs but were not trained or paid SPs. Nursing students usually practice assessment and communication skills with each other in a nursing laboratory and rotate the role of nurse and patient; however, it is not a realistic patient situation because both roles are portrayed by nursing students. Using pseudo-SPs provides realism during the health assessment practicum examination.

Process

The first step was to obtain volunteers from a prenursing course to act as pseudo-SPs. The pseudo-SPs completed a consent form and then were provided with a brief script that included their assigned fictitious name, allergies, reason for seeking care, basic family history, and a short medical history on the day of the assessment practicum testing. Nursing students were given 40 minutes to complete a comprehensive health assessment on an assigned pseudo-SP in a designated standardized patient clinic room at a clinical simulation center. At the end of the comprehensive health assessment, the pseudo-SP evaluated the nursing student with a short performance rubric that had a section for written comments. The nursing students were also graded by faculty on their communication skills, ability to take a basic health history, and ability to complete a comprehensive physical examination using the four assessment techniques of inspection, palpation, percussion, and auscultation. The pseudo-SPs were usually excited for the experience, whereas the nursing students were initially anxious; however, after the practicum examination was complete, both parties were amazed with their performance.

Program Evaluation

The pseudo-SP program was evaluated by both nursing students and pseudo-SP volunteers; in addition, faculty evaluated and graded the nursing students’ performance. A majority of nursing students (86%; 73 of 85) reported performing a comprehensive health assessment on a pseudo-SP increased their confidence with their assessment skills, whereas 92% (78 of 85) of the nursing students reported that their nursing assessment skills were challenged using a pseudo-SP. Nursing students acknowledged that although the realistic practicum challenged their assessment and communication skills, the challenge validated their knowledge base and confirmed that they were able to perform health assessments in a clinically simulated environment. Finally, 88% (75 of 85) of the nursing students reported increased competence in performing health assessments. For faculty, it was rewarding to witness the students’ success. Furthermore, nursing students provided written comments about advantages and disadvantages with using pseudo-SPs to perform a health assessment practicum test. Some of the comments and responses were:

  • Patient seemed real…the set up was realistic.
  • Helps you prepare for the real clinical setting.
  • Allows the student to use skills without knowing in advance anything about the patient and discourages preparation by memorizing a script.
  • Challenges student’s knowledge of assessment.
  • You learn how to describe your assessment in laymen’s terms to the patient.

The pseudo-SPs also completed a written questionnaire. All but two of the 63 pseudo-SP participants (97%) reported an increase in their interest in nursing as a profession, and 94% (59 of 63) reported an increased interest in the school of nursing. Pseudo-SPs’ comments included:

  • Gave me insight as to how in depth the range of knowledge [is that] I will be learning.
  • Gained deeper insight of the tasks entailed in the nursing profession.
  • It gave me a better idea about the beginning stages of the program and how a nurse should interact with patients.
  • I got a sneak peek into what I would be doing in the nursing program.

Faculty noted that communication skills during the health assessment practicum examination with a pseudo-SP were significantly different than those seen when students practiced on their classmates. Performing assessments on classmates, rather than on strangers or pseudo-SPs, is predictable and requires little instructional guidance. Classmates are familiar with the assessment content and often anticipate the examination, whereas pseudo-SPs require directions, demonstrations, and explanations of the assessment procedures. Faculty graded nursing students on their ability to give instructions, their ability to communicate effectively and professionally, and their mannerism and organization while completing the comprehensive health assessment.

Conclusion

A pseudo-SP program is a win–win combination. Nursing students perform assessments in a pseudosimulated environment, and prenursing students gain greater exposure into the nursing profession. Not only are nursing students gaining valuable experience but increasing interest in the nursing profession is a welcome bonus. A pseudo-SP program is an innovation that adds realism at a low cost and is worth considering in an undergraduate nursing program.

References

  • Anderson, M., Holmes, T.L., LeFlore, J.L., Nelson, K.A. & Jenkins, T. (2010). Standardized patients in educating student nurses: One school’s experience. Clinical Simulation in Nursing, 6, e61–e66. doi:10.1016/j.ecns.2009.08.001 [CrossRef]
  • Barrows, H. & Abrahamson, S. (1964). The programmed patient: A technique for appraising student performance in clinical neurology. Journal of Medical Education, 39, 802–805.
  • Barrows, H.S. (1993). An overview of the uses of standardized patients for teaching and evaluating clinical skills. Academic Medicine, 68, 443–451. doi:10.1097/00001888-199306000-00002 [CrossRef]
  • Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
  • Lehr, S.T. & Kaplan, B. (2013). A mental health simulation experience for baccalaureate student nurses. Clinical Simulation in Nursing, 9, e425–e431. doi:10.1016/j.ecns.2012.12.003 [CrossRef]
  • Owens, T.L. & Gilva-McConvey, G. (2015). Standardized patients. In Palaganas, J.C., Max-worthy, J.C., Epps, C.A. & Mancini, M.E. (Eds.), Defining excellence in simulation programs (pp. 199–212). New York, NY: Wolters Kluwer.

Shona M. Rue, MSN, CPNP, CNE
shona.rue@unlv.edu

Jessica Doolen, PhD, APRN-C, CNE
University of Nevada Las Vegas

The authors have disclosed no potential conflicts of interest, financial or otherwise.

References

  • Anderson, M., Holmes, T.L., LeFlore, J.L., Nelson, K.A. & Jenkins, T. (2010). Standardized patients in educating student nurses: One school’s experience. Clinical Simulation in Nursing, 6, e61–e66. doi:10.1016/j.ecns.2009.08.001 [CrossRef]
  • Barrows, H. & Abrahamson, S. (1964). The programmed patient: A technique for appraising student performance in clinical neurology. Journal of Medical Education, 39, 802–805.
  • Barrows, H.S. (1993). An overview of the uses of standardized patients for teaching and evaluating clinical skills. Academic Medicine, 68, 443–451. doi:10.1097/00001888-199306000-00002 [CrossRef]
  • Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
  • Lehr, S.T. & Kaplan, B. (2013). A mental health simulation experience for baccalaureate student nurses. Clinical Simulation in Nursing, 9, e425–e431. doi:10.1016/j.ecns.2012.12.003 [CrossRef]
  • Owens, T.L. & Gilva-McConvey, G. (2015). Standardized patients. In Palaganas, J.C., Max-worthy, J.C., Epps, C.A. & Mancini, M.E. (Eds.), Defining excellence in simulation programs (pp. 199–212). New York, NY: Wolters Kluwer.
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